Nursing Process: Panning Outcomes/ Interventions

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Care Planning

Back 1

Professional nurse is responsible for car planning, and cannot delegate.

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Formal Planning

Back 2

"is a conscious, deliberate activity involving decision making, critical thinking, and creativity."

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During the Planning Phases of the Nursing Process

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You will work with the patient and family to derive desired outcomes from identified patient problems (nursing diagnosis) & then to identify nursing interventions to help achieve those outcomes.

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End product of Formal Planning

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A holistic plan of care that addresses the patient's unique problems and strengths.

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Goals/Desired Outcomes

Back 5

Flow logically from the nursing diagnoses. By stating what is to be achieved, the goals then suggest nursing interventions.

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Plan of Care

Back 6

Carried out in the implementation phase.

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Evaluation Stage

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The goals/desired outcomes serve as criteria for evaluation whether the nursing care has been effective.

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Initial Planning

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Begins with the first patient contact. It refers to the development of the initial comprehensive care plan, which should be written as soon as possible after the initial assessment.

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Ongoing Planning

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Refers to changes made in the plan as you evaluate the patient's responses to care or as you obtain new data and make new nursing diagnosis.

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Discharge Planning

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The process of planning for self-care and continuity of care after the patient leaves a healthcare setting. Must being at the initial assessment.

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Discharge Planning Includes the Following Data

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Physical condition, functional, and self-care limitations

Emotional stability and ability to learn

Financial resources

Family or other caregivers available?

Caregiving responsibilities the patient may have for others

Environment, both home and community (stairs, space for supplies, transportation to healthcare services)

Use of community servcies before admission

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Discharge Planning for Older Adults

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Maintain functional ability

Lengthen the time between re-hospitalizations.

Involve all concerned parties in decision-making

Improve inter-agency communication.

Emphasize client and family involvement and interdisciplinary collaboration.

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Comprehensive Nursing Care Plan

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Also called patient care plan, is the central source of info needed to guide holistic, goal-oriented care to address each patient's unique needs. Specifies dependent, interdependent, and independent nursing actions necessary for care of a specific patient. Combines standardized and individualized approached to care.

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A well-written NCP is Important because...

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Benefits the patient and healthcare institution by: Ensure that care is complete, Providing continuity of care (kid will only eat red pops), promoting effective use of nursing efforts, providing a guide for assessments and charting, meeting the requirements of accrediting agencies.

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What info does a Comprehensive NCP contain?

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Directions for 4 different kinds of care and include both medical and nursing interventions:

1. Basic needs and activities of daily living

2. Medical/multi-disciplinary treatment (medications and nursing activities necessary for carrying out those orders

3. Nursing diagnoses and collaborative problems (goals and nursing orders for patient's nursing diagnoses and collaborative problems)

4. Special discharge needs for teaching needs

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Special-purpose or addendum Care Plans

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Contains one or more discharge or teaching plans.

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Rationales

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State the scientific principles or research that supports nursing interventions. Helps ensure that you understand the reasons for the interventions.

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Mind-Mapping

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Is a technique for showing relationships among ideas and concepts in a graphical, or pictorial, way. Includes parts of nursing process.

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Nursing Process

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Assessment data, nursing diagnoses, patient goals, interventions, and evaluation

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Process for Writing an Individualized NCP

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Follows in natural sequence from the assessment and diagnosis phases of the nursing process: Make a working problem list- Decide which problems can be managed with standardized care plans or critical pathways.

Individualize the standardized plan as needed. Transcribe medical orders to appropriate documents. Write ADLs and basic care need in special sections of the Kardex, Develop individualized care plans for problems not addressed by standardized docs.

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Goals

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After assessment and diagnosis, the next step in individualized care planning is to formulate goals for improving or maintaining the patient's health status. Goals/expected outcomes/desired outcomes/predicted outcomes- describe the changes in patient health status that you hope to achieve.

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Nursing-Sensitive Outcomes

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are those that can be influenced by nursing interventions.

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Goal/Expected Outcome Formulation

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The responsibility of the professional nurse.

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Absence of Pain

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Relaxed body posture, relaxed facial expression, does not complain of pain, states that his pain is relieved. Rates pain at less than 3 on a scale of 1-10.

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Problem Side of the Nursing Diagnosis

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Suggests the goals

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Etiology

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Suggests the nursing interventions. Goals derived from the etiology may help resolve the problem, but they could also be achieved without resolution of the problem.

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Essential Patient Goals

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Flow from the problem side of the nursing diagnosis because the problem side describes the unhealthy response you intend to change.

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Rules for Goals

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For every nursing diagnosis, you must state one goal that , if achieved, would demonstrate resolution or improvement of the problem.

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Collaborative Problems

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physiological complications of diseases (diabetes) or medical treatments (cardiac catheterization) that nurses monitor to detect onset of changes in status. Always the desired outcome is that the complication will not develop. Do not result primarily from nursing interventions.

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NOC Outcome

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"an individual, family, or community state, behavior, or perception that is measured along a continuum in response to nursing interventions." Consists of an outcome label, indicators, and a measurement scale.

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Outcome Label

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broadly stated (Decision Making, Mobility Level, concentration). You can look up a nursing diagnosis to see the list of outcomes suggested for it.

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Indicators

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are the observable behavior and states you can use to evaluate patient status. "Identifies relevant information." Indicates one way you could know that Decision Making (the broad outcome) was being achieved.

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Reflecting Critically About Expected Goals

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Is there at least one goal that, when met, would demonstrate problem resolution?

Do the predicted outcomes completely address the nursing diagnosis?

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Reflecting Critically About Expected Outcomes

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Is the outcome appropriate for the nursing diagnosis?

Is each outcome derived from only one nursing diagnosis?

Does each outcome describe only one patient response or behavior? Pg 99

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Reflecting Critically About Expected Outcomes, Continued..

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Is the outcome stated as a patient behavior, not a nurse activity?

Is the outcome stated in positive terms?

Is the outcome measurable or observable?

Are the performance criteria specific and concrete? (Avoid normal, sufficient, enough, more, less , adequate, increased).

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Reflecting Critically About Expected Outcomes, Continued...

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Does each goal include all the necessary parts? (Subject, action verb, performance criterion, target time, and special condition, when needed)

Is the expected outcome realistic and achievable by this patient, give the available resources?

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Reflecting Critically About Expected Outcomes, Continued...

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Does the outcome conflict with the medical or other laborative treatment plan?

Does the patient, family, or community value the outcome?

Does the goal conflict with any religious or cultural values?

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Nursing Interventions

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Are actions, based on clinical judgment and nursing knowledge, that nurses perform to achieve client outcomes. Also referred to as nursing actions, measures, strategies, and activities.

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Direct Care Intervention

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performed through interaction with the client(s). Direct-care activities include physical care, emotional support, and patient teaching.

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Indirect Care Intervention

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performed away from the client but on behalf of a client or group of clients. Indirect care activities include advocacy, managing the environment, consulting with other members of the healthcare team, and making referrals.

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Autonomous

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*Independent* knowing how, when, and why to perform an activity makes the action autonomous.

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Accountable

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*Answerable* for your decisions and actions with regard to nursing diagnoses and independent interventions.

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Independent Intervention

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One that registered nurses are licensed to prescribe, perform, or delegate based on their knowledge and skills. It does not require a provider's order.

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Dependent Intervention

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One that is prescribed by a physician or advanced practice nurse but carried out by the bedside nurse. Usually orders for diagnostic tests, medications, treatments, IV therapy, diet, and activity.

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Interdependent (Collaborative) Intervention

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One that is carried out in collaboration with other health team members.

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How do I decide which Intervention to Use?

Back 46

Box 6-1 on page 104

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Theory

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A set of interrelated concepts (ideas) that describes or explains something-nursing, for example. A theory, like a lens, influences your perspective: what you notice, what you consider to be a problem- and how you define a problem-more or less determine what you choose to do about it.

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One competency you should achieve in nursing school...

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To differentiate clinical opinion from research and evidence summaries.

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Research-based support for an intervention includes:

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Single studies, critical pathways and protocols, clinical practice guidelines, systematic reviews of the literature, and evidence reports.

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PICOT

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Questions that help you use evidence to decide which interventions to use.

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Critical Pathways

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Also called clinical pathways and collaborative care plans. Are standardized plans of care for frequently occurring conditions (total hop replacement) for which similar outcomes and interventions are appropriate for all patients who have the condition.

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Interventions (THINK OF CAT)

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Assess

Monitor

Action

Administer

Collaborate

Educate

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Evidence-based Practice

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An approach that uses firm scientific data rather than an anecdote, tradition, intuition, or folklore in making decisions about medical and nursing practice.

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Nursing Strategy

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Can be a preventive measure in one situation and a treatment in another. Example: Refer to lactation consultant for breastfeeding assistance" to treat a woman with an actual diagnosis of ineffective breast feeding or to help prevent the problem for a women with a diagnosis of Risk for Ineffective Breastfeeding.

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How to select the best Interventions?

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Review the nursing diagnosis

Review the desired patient outcomes

Identify several interventions or actions

Choose the best interventions for that patient

Individualize standardized interventions to meet the patient's unique needs.

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Review The Nursing Diagnosis

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Choose strategies you expect will reduce or remove the etiological factors of actual problems or that will reduce or remove risk factors for potential problems.

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Review the Desired Patient Outcomes

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Desired outcomes (goals) suggest nursing strategies that are specific to the individual patient.

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Interventions & Goals

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There may be one or more interventions for each goal, and a single intervention may help to achieve more than one goal. There is no strict one-to-one correspondence between goals and interventions.

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Identify Several Interventions or Actions

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To get started, ask yourself: for the nursing diagnosis, (1) what assessments/observations do I need to make? (2) What do I need to do for the patient? Include both independent & dependent activities as appropriate.

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Chose the Best Interventions for the Patient

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Contextual awareness

Credible Sources

Considering Alternatives

Analyze Assumptions

Reflecting skeptically

Does it have any potential ill effects? If so how will we manage them?

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Nursing Orders

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are instructions, usually written on a nursing care plan, that describe how and when nursing interventions are to be implemented.

*Date, Subject (nurse behaviors), action verb, times & limits, signature.

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Implementation

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Think of implementation as the action phase of the nursing process. Of, course implementation involves both thinking and doing, but the emphasis is on doing.

Doing, Delegating, & Documenting

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During the Implementation

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You will perform or delegate planned interventions- this is carry out the care plan.

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The Implementation Phase Ends When...

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You document the nursing actions in the chart; it evolves into evaluation s you document the resulting client responses.

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How is Implementation Related to Other Steps of the Nursing Process

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Without the assessment, diagnosis, and planning steps, implementation would reflect only dependent functions, such as carrying out policies, protocols, and medical orders.

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Implementation overlaps with assessment

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Nurses use assessment data to individualize interventions for a specific person rather than just giving "routine care."

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Implementation overlaps with diagnosis

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Nurses use data discovered during implementation to identify new diagnoses or to revise existing ones.

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Implementation overlaps with planning outcomes & interventions

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When you implement a nursing intervention, it produces patient responses. Patient responses provide the data you need for revising the original goals and nursing orders.

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Implementation Overlaps with Evaluation

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When evaluating patient health status and progress toward goals, you will compare the responses you observe during implementation to the existing goals (which were written in the planning outcomes phase)

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Must look for Feedback

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How the patient is responding to the activity as you perform care. In a sense this is evaluating but because it is done before the intervention we call it feedback.

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Implementation Plan Doing or Delegating

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Nursing actions include both those you do yourself and you delegate to others; and they may be collaborative, independent, or dependent.

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During Implementation

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You will coordinate and carry our both the nursing orders on the nursing car plan and the medical orders that relate to the patient's medical treatment.

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True Collaboration

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requires shared decision-making

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Coordination of Care

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Includes scheduling treatments and activities with other departments (lab, physical therapy, radiology) Nurses are responsible for more than that, they need to be able to see the WHOLE picture (how they react to PT etc.)

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Delegation

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The process of directing another person to perform a task or activity; it is a transfer of authority or responsibility. The person delegating retains accountability for the outcome of the activity. You can only delegate down the chain of command.

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Communication for Delegation

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1. Explain exactly what the task is

2. Include specific times and methods for reporting

3. Explain the purpose or objective of the task

4. Describe the expected results or potential complications to expect.

5. Be specific in your instructions

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Documenting: The Final Step of Implementation

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After giving care, you will record the nursing activities and the patient's responses.

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Evaluation (The final step)

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A planned, ongoing, systematic activity in which you will make judgments about:

1. Client's progress toward desired health outcomes

2. The effectiveness of the nursing care plan.

3. The quality of nursing care in the healthcare setting

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Why is Evaluation Essential to Full-Spectrum Nursing?

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The patient is the nurse's first priority.

Evaluation helps nurses to conserve scarce resources.

Professional Standards of practice require evaluation.

THE ANA Code Ethics require evaluation.

The Joint Commission & Professional standards review organizations require evaluations.

Evaluation helps ensure nursing's survival.

Evaluation demonstrates caring & responsiblity

Quality and safety education for Nurses.

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Formal Evaluation

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You must decide in advance which standards and criteria you will use.

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Standards

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Represent expected or accepted levels of performance; they provide a model for what ought to be done. Standards are used to describe quality nursing care.

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Criteria

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Are measurable or observable characteristics, properties, attributes, or qualities. They describe the specific skills, knowledge, behaviors and attitudes that are desired or expected. (Patient goals and outcomes)

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Reliable

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A criterion is reliable if ti yields consistent results-that is, the same results every time, regardless of who uses it.

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Valid

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A criterion is valid if it is really measuring what it was intended to measure. For example, fever is often used as a criterion for concluding that a person has an infection. However, if used alone it is not a valid indicator because other conditions can cause a fever.

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Types of Evaluation

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What is being evaluated (structures, processes, or outcomes)

Frequency and time of evaluation

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Structure Evaluation

Back 86

Focuses on the setting in which care is provided. It explores the effect of organizational characteristics on the quality of care. It recognizes standards and date about policies, procedures, fiscal resources, physical facilities and equipment, and # of qualifications of personnel. At least one RN is present on each unit at all times.

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Process Evaluation

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Focuses on the manner in which care is given- the activities performed by nurses (and other personnel). Protects patient's privacy when performing procedures. Washes hands before each patient contact.

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Outcomes Evaluation

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Focuses on observable or measurable changes in the patient's health status that result from the care given. The most important aspect is improvement in patient health status. Patient will walk, assisted, to the end of hall by day five postop. Also used when evaluating quality of are in an organization.

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Ongoing Evaluation

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You will perform ongoing evaluation while implementing, immediately after an intervention and at each patient contact.

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Intermittent Evaluation

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Performed at specified times.

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Terminal Evaluation

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Describes the client's health status and progress toward goals at the time of discharge. Includes instructions on medication, treatments, and follow-up care.

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Evaluation Overlaps Greatly with Assessment

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The difference is in when you collect the data. Assessment data are collected before interventions are performed.

Evaluation data are collected after interventions are performed.

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Evaluation does not "end" the nursing process

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It merely provides the info you need to begin another cycle. After giving care you compare pt responses to the desired outcomes (goals) and use that info to reflect critically on the care plan and each step of the nursing process as it applies to that patient.

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When evaluating patient progress..

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You review the desired outcomes, collect reassessment data, judge whether goals have been met, and record the evaluative statement.

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Review Outcomes

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First, review the goals/outcomes on the patient's care plan. The goals and indicators you identified in the planning outcomes phase suggest the kind of assessments you need to make and provide criteria by which to judge.

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Reassessment

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Assessments made for the purpose of evaluation. Always focused assessments.

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Judge Goal Achievement

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Achieved, Partially achieved, or Not achieved.

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An Evaluation Statement Should Include...

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The conclusion about whether the goal was achieved.

Reassessment data to support the judgment.

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Goals for Collaborative Problems

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Are not included on the nursing car plan, and the evaluation process is slightly different.

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As long as the Pt has the medical condition...

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The collaborative problem still exists. If the reassessment data are within normal limits, this does not mean the collaborative problem is resolved- only that the complication has not occurred.

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Evaluating and Revising the Care Plan

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After evaluating pt progress, you will use your conclusions about goal achievement to decide whether to continue, modify, or discontinue the care plan.

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Most Common Errors of Evaluating

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Failing to to:

Evaluate systematically

Record the results

Use the reassessment data to examine and modify the care plan.